UCLA

Objective

Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR.

Study design

We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY).

Results

In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.

Conclusion

Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources.

Key points

· Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..